Symposium on Complex Care – materials and promising practices
Why Complex Care?
Policymakers, payers, and providers of health care are increasingly focused on improved models of care for high-need, high-cost patients, a relatively small group of individuals who account for a significant portion of health care costs, and are very often high utilizers of other systems as well (e.g., criminal justice, housing assistance). In addition to their complex medical and/or behavioral health needs, these patients often face a number of social and economic challenges that further complicate their health outcomes-including, for example, lack of employment, housing instability, social isolation, and food insecurity.
What We Do
Redwood Community Health Coalition is running a learning collaborative with six of its community health centers to develop and pilot a standard care management training program for the clinics’ multi-disciplinary complex care teams. The trainings focus on the following:
- Developing the core skills needed to provide effective complex care management;
- Identifying a standard set of social determinants of health metrics to track, and training on how to incorporate SDH data collection into health center workflows; and
- Ensuring health centers are prepared for rollout of California’s Medicaid Health Homes (Section 2703) in 2017.
Who We Serve
Patients with complex needs are defined as Medi-Cal beneficiaries having one or more of the following characteristics:
- Serious mental illness or substance use disorders;
- High emergency department or hospital utilization;
- Multiple prescriptions;
- Chronic illnesses and pain; and
This project is funded by the Robert Wood Johnson Foundation.
May 2016 through April 2018
MEASURES & GUIDELINES
The project team will conduct an initial qualitative analysis to determine how learning collaborative trainings impacted participants’ abilities to serve complex patients. In addition to interviewing representatives from three participating health centers, RCHC staff will also interview representatives from three RCHC health centers that did not participate in the collaborative. We will conduct in-depth open-ended interviews about how each site cares for complex patients. We will compare responses and issues raised between both collaborative and non-collaborative health centers.
Additionally, RCHC will work with Rutgers staff to design a more robust evaluation (including a data collection and analysis strategy) that can be carried out by RCHC at project end.
Results of this project will be available in April 2018.
- Alexander Valley Healthcare
- Marin Community Clinics
- Petaluma Health Center
- Santa Rosa Community Health
- Sonoma Valley Community Health Center
- West County Health Centers
- Robert Wood Johnson Foundation
- Center for Health Care Strategies
- Partnership HealthPlan
- Rutgers University
For more information, please contact Claire Cain
ALIGNMENT WITH OTHER INITIATIVES
- HRSA HCCN Grant (Social Determinants of Health)
- CMSP Grant (Social Determinants of Health)
- NACHC BSCF Grant (Social Determinants of Health)
- Medicaid Health Homes Section 2703
- Partnership HealthPlan’s Intensive Outpatient Case Management project
ADDITIONAL RESOURCES AND COMPANION DOCUMENTS
- CHCS Project Portal: http://www.chcs.org/tcc-portal/
- Learning Collaborative Training Recordings:
- Symposium on the Future of Complex Care – 2017
Symposium Presentation Materials
In November 2017, RCHC hosted the Symposium on the Future of Complex Care.
The materials from the sessions are included here:
- Keynote Address
CPCA, Andie Patterson, MPP, Director of Government Affairs
- Impactful Strategies for Documenting Complex Conditions and Social Determinants of Health
MedPoint Management, Linda Deaktor, VP, Quality Management
CPCA, Lucy Moreno, MPH, PCMH CCE, Data Informaticist
RCHC, Danielle Oryn, DO, MPH, CMO/CMIO
- Adopting a Risk Stratification Model That Utilizes EHR Data
Contra Costa Health Services, Daniel Brown, PhD, Data Scientist
RCHC, Danielle Oryn, DO, MPH, CMO/CMIO
- Engaging in Health Information Exchange for Care Transitions
Humboldt IPA, Jessica Osborne-Stafsnes, MSHS and Kim Perris, MSN, RN, CNL
RCHC, Lisa Israel, MBA, CPHQ, CPHIMS, Project Manager
- Using Technology for Complex Care Management
Partnership HealthPlan of California, James Cotter, MD, MPH, Regional Medical Director
Marin City Health & Wellness, Remy Mercer-Slomoff, MS
RCHC, Claire Cain, MPH, Program Manager
Health Center Promising Practices
The RCHC member health centers shared promising practices at the Symposium on Complex Care. Please visit our Evidence Based Care page to see these and all of the RCHC member promising practices